Delayed mesencephalic venous infarction after endovascular treatment of a giant aneurysm of the posterior cerebral artery: Case report and anatomical review.
ABSTRACT: A 54-year old male patient underwent stent reconstruction of the P1-2 segment of the left posterior cerebral artery (PCA) and concomitant coil embolization of a symptomatic giant partially thrombosed P1 segment aneurysm. After an uneventful postinterventional period, on the 7th day the patient developed severe disturbance of consciousness. The imaging workup demonstrated acute venous infarction in the midbrain, caused by the compressive occlusion of the median anterior pontomesncephalic vein by the aneurysm in the interpeduncular fossa.
Project description:In Joubert syndrome, the "molar tooth" sign can be associated with several additional supra- and infratentorial malformations. Here we report on 3 subjects (2 siblings, 8-14 years of age) with Joubert syndrome, showing an abnormal thick bulging of the anterior profile of the mesencephalon causing a complete obliteration of the interpeduncular fossa. DTI revealed that the abnormal tissue consisted of an ectopic white matter tract with a laterolateral transverse orientation. Tractographic reconstructions support the hypothesis of impaired axonal guidance mechanisms responsible for the malformation. The 2 siblings were compound heterozygous for 2 missense variants in the TMEM67 gene, while no mutations in a panel of 120 ciliary genes were detected in the third patient. The name "anterior mesencephalic cap dysplasia," referring to the peculiar aspect of the mesencephalon on sagittal MR imaging, is proposed for this new malformative feature.
Project description:<h4>Background</h4>Despite ongoing improvements in endovascular techniques, open surgical management of basilar apex aneurysms is occasionally necessary. Critical dissection of perforating vessels from the aneurysm is facilitated by the lateral trajectory of the subtemporal approach. Incorporation of additional trajectories can facilitate treatment of multiple aneurysms within the same procedure.<h4>Case description</h4>A 48-year-old woman presented with a Hunt and Hess 1 and Fisher Grade 3 subarachnoid hemorrhage from a small and broad-necked basilar apex aneurysm that was not amenable to endovascular management. An unruptured left A1-A2 anterior cerebral artery aneurysm was also noted on vascular imaging. The patient underwent a combined right subtemporal and pterional approach for sequential clipping of the basilar and anterior communicating artery aneurysms. The third nerve, running between the posterior cerebral artery and the superior cerebellar artery, guided dissection to the basilar artery in the subtemporal approach. A temporary clip was placed on a vessel-free zone of the basilar trunk during dissection of perforators off the posterior aspect of the aneurysm dome. A fenestrated clip around the right P1 segment was used to ensure complete occlusion of the aneurysm. Indocyanine green angiography was used to confirm successful clipping and patency of parent and perforating vessels. The unruptured A1-A2 aneurysm was clipped without difficulty from the pterional trajectory. The patient had an uneventful postoperative recovery with the exception of transient right third nerve palsy.<h4>Conclusion</h4>As highlighted by this case, maintenance of open surgical skills for the treatment of complex aneurysms unamenable to endovascular therapies is critical.
Project description:BACKGROUND:Partially thrombosed giant aneurysms at the basilar apex (BA) artery are challenging lesions with a poor prognosis if left untreated. Here we describe a rare case of extensive brain edema after growth of a surgically treated and thrombosed giant basilar apex aneurysm. CASE PRESENTATION:We performed a proximal surgical basilar artery occlusion on a 64-year-old female with a partially thrombosed giant BA aneurysm. MRI showed no ischemic lesions but showed marked edema adjacent to the aneurysm. She had a good recovery, but 3 months after surgical occlusion, her gait deteriorated together with urinary incontinence and worsening right hemiparesis. MRI showed that the aneurysm had grown and developed intramural hemorrhage, which caused extensive brain edema and obstructive hydrocephalus. She was treated by a ventriculoperitoneal shunt placement. Follow-up MRI showed progressive brain edema resolution, complete thrombosis of the lumen and shrinkage of the aneurysm. At 5?years follow-up the patient had an excellent functional outcome. CONCLUSIONS:Delayed growth of a surgically treated and thrombosed giant aneurysm from wall dissection demonstrates that discontinuity with the initial parent artery does not always prevent progressive enlargement. The development of transmural vascular connections between the intraluminal thrombus and adventitial neovascularization by the vasa vasorum on the apex of the BA seems to be a key event in delayed aneurysm growth. Extensive brain edema might translate an inflammatory edematous reaction to an abrupt enlargement of the aneurysm.
Project description:A 68-year-old woman presented with generalized seizure due to the left internal carotid artery (ICA) aneurysmal compression of the ipsilateral medial temporal lobe. Computed tomography angiography (CTA) revealed multiple aneurysms of the right persistent primitive hypoglossal artery (PPHA), the right ICA, and the right anterior cerebral artery (ACA). The right PPHA originated from the ICA at the level of the C1 and C2 vertebral bodies and passed through the hypoglossal canal (HC). The PPHA aneurysm was large and thrombosed, which was located at the bifurcation of the right PPHA and the right posterior inferior cerebellar artery (PICA), projecting medially to compress the medulla oblongata. Since this patient had no neurological deficits, sequential imaging studies were performed to follow this lesion, which showed gradual growth of the PPHA aneurysm with further compression of the brain stem. Although the patient remained neurologically intact, considering the growing tendency clipping of the aneurysm was performed. Drilling of the condylar fossa was necessary to expose the proximal portion of the PPHA inside the HC. The key of this surgery was the preoperative imaging studies to fully understand the anatomical structures. The PPHA was fully exposed from the dura to the corner its turning inferiorly without damaging the occipital condylar facet. Utilizing this technique, the neck ligation of the aneurysm was safely achieved without any surgical complications.
Project description:<h4>Background and purpose</h4>Treatment options for nonsaccular posterior cerebral artery aneurysms include a range of surgical and endovascular reconstructive and deconstructive methods. However, no truly satisfactory treatment option is available to date for lesions arising from the P1 and P2 segments. The purpose of the present case series is to investigate both the efficacy and safety of the Pipeline Embolization Device in treating these challenging aneurysms.<h4>Materials and methods</h4>We present a series of 6 consecutive patients who underwent endoluminal reconstruction with the Pipeline Embolization Device for nonsaccular P1 or P2 segment aneurysms between January 2009 and June 2013.<h4>Results</h4>Aneurysm location included the P1 segment in 2 patients and the P2 segment in 4 patients. Mean aneurysm diameter was 23 mm (range, 5-44 mm). Mean length of the arterial segment involved was 10 mm (range, 6-19 mm). Clinical presentation included mass effect in 4 patients and perforator stroke and subacute aneurysmal subarachnoid hemorrhage in 1 patient each. Endovascular reconstruction was performed by using 1 Pipeline Embolization Device in 5 patients and 2 overlapping Pipeline Embolization Devices in the remaining patient. Angiographic aneurysm occlusion was immediate in 1 patient, within 6 months in 4 patients, and within 1 year in the remaining patient. Index symptoms resolved in 4 patients and stabilized in the remaining 2. No new permanent neurologic sequelae and no aneurysm recurrence were recorded during the mean follow-up period of 613 days (range, 540-725 days).<h4>Conclusions</h4>Endovascular reconstruction with the Pipeline Embolization Device for nonsaccular aneurysms arising from the P1 and P2 segments compares favorably with historical treatment options in terms of occlusion rate, margin of safety, and neurologic outcome.
Project description:<h4>Background and purpose</h4>Patients with fusiform basilar trunk aneurysms have a poor prognosis. Reconstructive endovascular therapy is possible with modern devices. We describe the clinical presentation, radiologic features, and clinical outcome of 13 patients with fusiform basilar trunk aneurysms treated with flow diverters, stents, and coils.<h4>Materials and methods</h4>Of the 13 patients, 7 were men and 6 were women with a mean age of 59.7 years. Clinical presentation was SAH in 3 patients, mass effect on the brain stem in 4 patients, vertebral artery dissection in 1 patient, and the aneurysm was an incidental finding in 5 patients. Mean aneurysm size was 21 mm. All except 1 were large or giant aneurysms. Nine aneurysms were partially thrombosed.<h4>Results</h4>Stents were used in all 13 patients, in 2 patients with additional flow diverters and in 11 patients with additional coils. In 4 patients, 1 vertebral artery was subsequently occluded with coils to decrease flow into the aneurysm. Of 13 patients, 9 had a good outcome with adequate aneurysm occlusion and stable size on follow-up of 6-72 months. One of 3 patients who presented with SAH died of a rebleed 1 month later. One other patient died soon after treatment of in-stent thrombosis, and another patient became mute after treatment. In 2 of 3 patients who presented with symptoms of mass effect, there was improvement at a follow-up of 6-24 months.<h4>Conclusions</h4>Reconstructive endovascular therapy of fusiform and dissecting basilar trunk aneurysms is feasible but carries substantial risks. The safety and effectiveness in relation to natural history has not yet been elucidated.
Project description:The Food and Drug Administration has approved devices for endovascular management of thoracic endovascular aortic aneurysm repair (TEVAR); however, limited data exist describing the outcomes of TEVAR for aneurysms attributable to chronic type B aortic dissection (cTBAD). This study was undertaken to determine the results of endovascular treatment of cTBAD with aneurysmal degeneration.A retrospective analysis of all patients treated for cTBAD with aneurysmal degeneration at the University of Florida from 2004 to 2011 was performed. Computed tomograms with centerline reconstruction were analyzed to determine change in aortic diameter, relative proportions of aortic treatment lengths, and false lumen perfusion status. Reintervention and mortality were estimated using life-tables. Cox regression analysis was completed to predict mortality.Eighty patients underwent TEVAR for aneurysm due to cTBAD (mean age [± standard deviation], 60 ± 13 years [male, 87.5%; n = 70]; median follow-up, 26 [range, 1-74] months). Median time from diagnosis of TBAD to TEVAR was 16 (range, 1-72) months. Prior aortic root/arch replacement had been performed in 29% (n = 23) at a median interval of 28.5 (range, 0.5-312) months. Mean preoperative aneurysm diameter was 62.0 ± 9.9 mm. In 75% (n = 60) of cases, coverage was proximal to zone 3, and 24% (n = 19) underwent carotid-subclavian bypass or other arch debranching procedure. Spinal drains were used in 78% (pre-op 71%, n = 57; post-op 6%, n = 5). Length of stay was 6.5 ± 4.7 days with a composite morbidity of 26% and in-hospital mortality of 2.5% (n = 2). Overall neurologic event rate was 17% (spinal cord ischemia 10% [n = 8], with a permanent deficit observed in 6.2% [n = 5]; stroke 7.5%). Aneurysm diameter reduced or stabilized in 65%. The false lumen thrombosed completely within the thoracic aorta in 52%, and reintervention within the treated aortic segment was required in 16% (n = 13).One- and 3-year freedom from reintervention (with 95% confidence interval [CI]) was 80% (range, 68%-88%) and 70% (range, 57%-80%), respectively. Survival at 1 and 5 years was 89% (range, 80%-94%) and 70% (range, 55%-81%) and was not significantly different among patients requiring reintervention or experiencing favorable aortic remodeling. Multivariable analysis identified coronary artery disease (hazard ratio [HR], 6.4; 95% CI, 2.3-17.7; P < .005), prior infrarenal aortic surgery (HR, 8.6; 95% CI, 2.3-31.7; P = .001), and congestive heart failure (HR, 11.9; 95% CI, 1.9-73.8; P = .008) as independent risk factors for mortality. Hyperlipidemia was found to be protective (HR, 0.2; 95% CI, 0.05-0.6; P = .004). No significant difference in predictors of mortality were found between patients who underwent reintervention vs those who did not (P = .2).TEVAR for cTBAD with aneurysmal degeneration can be performed safely but spinal cord ischemia rates may be higher than previously reported. Liberal use of procedural adjuncts to reduce this complication, such as spinal drainage, is recommended. Reintervention is common, but long-term survival does not appear to be impacted by remediation.
Project description:Introduction:A true brachial artery aneurysm is a rare pathology with an incidence of 0.17% of all peripheral artery aneurysms. This pathology can manifest devastating complications if overlooked, however, a high index of suspicion coupled with a thorough history and physical allows easy diagnosis. We present a rare case of the oldest documented patient with a true brachial artery aneurysm with idiopathic etiology. Presentation of case:An 83-year-old gentleman presented with left upper extremity pain, erythema, and swelling for 1 week. He denied trauma to the area. Examination revealed a pulsatile mass of the antecubital fossa and decreased distal pulses. Imaging illustrated a 9mm aneurysm of the brachial artery with stenosis of the radial artery and non-enhancement of the origin of the ulnar artery. The patient underwent a brachial aneurysm excision, radial and ulnar embolectomy, and brachial to ulnar and radial artery bypass. Postoperatively, palpable pulses were appreciated in the radial and ulnar arteries. Pathology demonstrated a true aneurysm. The patient's postoperative course was uneventful and follow-up 6 months later revealed normal perfusion. Discussion:This case highlights the importance of maintaining a high index of suspicion coupled with a thorough history and physical examination when encountering neurovascular complaints of the upper extremities. Operative intervention even in asymptomatic patients is warranted due to a high complication rate of 33%. Conclusion:More research into the pathophysiology of this rare pathology is needed to further understand, prevent, or mitigate its complications.
Project description:Background:Giant thrombosed vertebral artery aneurysms (GTVAs) are difficult disease to treat. Here, we are reporting a case of GTVA successfully treated with excluding the pathological segment and restoring the anterograde blood flow of the parent artery, highlighting the reliable surgical procedure. Case Description:A 55-year-old man with a left GTVA complained of right hemiparesis (manual muscle testing 4/5) represented by hand clumsiness and gait disturbance, in addition to severe left-sided dysesthesia, was referred to our hospital. The posterior inferior cerebellar artery (PICA) was incorporated into the GTVA segment, and the contralateral vertebral artery showed atherosclerotic change. Thus, we decided to treat the aneurysm with aneurysm trapping and thrombectomy, in conjunction with V3-radial artery graft (RAG)-V4 bypass and occipital artery (OA)-PICA bypass through a suboccipital transcondylar approach. The distal end of the dilated segment was meandering and deflecting outwardly to the vicinity of the internal auditory canal and was stretched in an axial direction. Thus, the V4 stump can be transposed to the triangle space made by the medulla, lower cranial nerves, and sigmoid sinus, and we could perform a safe and reliable anastomosis through the corridor. After the surgery, the compression of the brain stem was released, and right hemiparesis was improved completely after rehabilitation. The patient was discharged with a modified Rankin Scale score of 1. Conclusion:Trapping of the aneurysm and thrombectomy are the most radical treatment for GTVA, and if possible, reconstruction of anterograde blood flow with V3-RAG-V4 bypass and OA-PICA bypass is desirable.
Project description:<h4>Background</h4>Endovascular aneurysm repair (EVAR) has been a revolutionary development in the treatment of abdominal aortic aneurysms (AAAs). Meanwhile, unfavorable anatomy of the aneurysm has always been a challenge to vascular surgeons, and the application of EVAR in emergent and elderly patients are still in dispute.<h4>Case presentation</h4>A 79-year-old woman presented as an emergency of abdominal pain with acute hypotension, heart rate elevation and a rapid decrease of hemoglobin. Emergent computed tomographic angiography (CTA) showed a ruptured AAA (rAAA) extending from below the opening of bilateral renal arteries down to the celiac artery and elongated to both common iliac arteries. The hostile neck and severely tortuous iliac artery made the following procedure a great challenge. An emergent endovascular approach was performed in which an excluder aortic main body was deployed below the origin of the bilateral renal arteries covering the ruptured aortic segment. Two iliac legs were placed superior to the opening of the right hypogastric respectively. In order to avoid the type Ib endoleak, we tried to deploy another cuff above the bifurcation of the iliac artery. However, the severely tortuous right iliac artery made this procedure extremely difficult, and a balloon-assisted technique was used in order to keep the stiff wire stable. Another iliac leg was placed above the bifurcation of the left iliac artery. The following angiography showed a severe Ia endoleak in the proximal neck and therefore, a cuff was deployed distal to opening of the left renal artery with off-the-shelf solution. The patient had an uneventful recovery with a resolution of the rAAA. She is well and symptom-free 6 months later.<h4>Conclusion</h4>Endovascular aneurysm repair (EVAR) in emergent elderly rAAA with hostile neck and severe tortuous iliac artery is extremely challenging, and endovascular management with integrated technique is feasible and may achieve a satisfactory early result.